counseling in communication disorders

Counseling in Communication Disorders

A Wellness Perspective

Third Edition

Counseling in Communication Disorders

A Wellness Perspective

Third Edition

Audrey L. Holland, PhDRyan L. Nelson, PhD

5521 Ruffin RoadSan Diego, CA 92123

e-mail: [email protected]: http://www.pluralpublishing.com

Copyright © 2020 by Plural Publishing, Inc.

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Library of Congress Cataloging-in-Publication Data:Names: Holland, Audrey L., author. | Nelson, Ryan L., author.Title: Counseling in communication disorders : a wellness perspective / Audrey L. Holland, Ryan L. Nelson.Description: Third edition. | San Diego, CA : Plural Publishing, Inc., [2020] | Includes bibliographical references and index.Identifiers: LCCN 2018021599| ISBN 9781635500455 (alk. paper) | ISBN 1635500451 (alk. paper)Subjects: | MESH: Communication Disorders--psychology | Counseling--methods | Family RelationsClassification: LCC RC428.8 | NLM WL 340.2 | DDC 616.85/506--dc23LC record available at https://lccn.loc.gov/2018021599

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Contents

Foreword by Nickola Wolf Nelson viiIn Memoriam ixForeword by Shirley Morgenstein xiPreface xiiiContributors xv

1 Counseling in Clinical Practice: Overview 1

2 Positive Psychology: In Brief 25

3 Good Counselors: Knowledge, Skills, Characteristics, and Attitudes 63

4 Communication Counseling With Parents of 107 Children With or At Risk for Disability With Holly Damico and Jack Damico

5 Counseling Issues With Children Who Have 165 Communication Disorders

6 Communication Counseling With Adult Clients 207 and Their Families for Whom Progression is Toward Improvement

7 Communication Counseling With Adult Clients 257 and Their Families for Whom Progression is Toward Deterioration

8 There’s an Elephant in the Room: Issues in 297 Death and Dying Stan Goldberg

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9 Teaching Resilience and Optimism to Families 317 and Persons

Index 353

vii

ForeWordby niCkola Wolf nelson

“No pessimist ever discovered the secret of the stars or sailed an uncharted land, or opened a new doorway for the human spirit.”

Helen Keller 1890–1968

Helen Keller’s words about optimism, growth, and discovery, which I selected for the foreword to the first edition of this book, fits the current edition perfectly as well. In this edition, Audrey Holland and her coauthor, Ryan Nelson, have maintained Holland’s original emphasis on adopting a positive theoretical and philosoph-ical perspective on counseling individuals with communication dis-orders. This starts with identifying what is right with people who have communication disorders as a means to help them and their families mobilize their strengths to deal with the adversities that have befallen them as a result of an unexpected event. By making positive psychology the “theoretical heart” of this book, Holland and Nelson show clinicians (in training or on the firing line) how to help their students, clients, patients, and families see their glasses as half full rather than half empty.

Positive psychology has evolved, however, since 2006–2007 when the first edition was written. In edition 2, Audrey and Ryan, following the lead of positive psychology, expanded the model toward showing how clinicians can augment their central work on improving speech, language, and audition by giving equal footing to engagement, relationship with others, meaning, and accomplish-ment. Recently, newer voices of positive psychology have increas-ingly acknowledged the complementary darker side of human experience, the “yin,” as it were, in what has been termed “second wave positive psychology.” This seems particularly appropriate given that the counseling needs of those we serve are, to some extent, rooted in trauma, and Audrey and Ryan welcomed this work, as they have the fascinating topic of post traumatic growth.

viii Counseling in CommuniCation DisorDers

All of these concepts fit snugly with a fundamental view of human communication as central to personal growth and a key to interpersonal interaction. Although the focus remains on central characters, Audrey and Ryan have built on working with the sup-porting cast within the communicative systems and networks in which individuals with communication disorders are situated. This includes broadening childhood concerns to focus more explicitly on family involvement in clinical work by speech-language patholo-gists and audiologists engaged in early intervention, as well as focusing more attention on the school environment (here building on one of Ryan’s strengths) for children in their school-age years. Finally, they have broadened the organizational themes beyond wellness, crisis and catastrophe, narrative, and shared expertise to include the theme of change. Change, in fact, is the meta-goal, the bread and butter, of all clinical efforts.

In my foreword to the previous editions of this work, I stressed my admiration for Audrey’s contributions over the years to under-standing the essentially social role of language and how that is buffeted about by communication problems. Her view of com-munication as something authentic, meaningful, and (potentially) fun has set a course for me in much of my research and practice. Ryan Nelson clearly shares her values. In fact, Audrey calls him my descendent. Ryan’s passion and respect for children and their families, and the importance of context and self-image, are manifest in this book’s child chapters, and if that makes him my descendant, I am happy to claim him.

Along with Audrey and Ryan, I recognize the pervasive need for communication specialists to incorporate counseling principles into their practice. Thus, I am extremely pleased to be able to offer this foreword to an updated and expanded version of their unconventional and practical approach to accomplishing that goal.

Nickola Wolf NelsonProfessor EmeritusDepartment of Speech Pathology and AudiologyWestern Michigan University, Kalamazoo, MI

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in memory oF Shirley Morganstein

(1946–2018)

Shirley Morgenstein was a model of resilience and optimism amidst catastrophe. She and Audrey have crafted the sweetest friendship over the years. In a recent communication, Shirley shared what we believe represents a perfect foreword to this edition of our book. Even though Shirley ideas are geared explicitly toward a primarily adult-oriented, medical-service model, we think the spirit of her words apply to any setting in which speech-language pathologists and audiologist operate. Unfortunately, school systems and private practices geared toward children typically embrace the medical models of practice Shirley laments. Too often, the person (regardless of age) with communication disorders is approached as diseased and in need of prescriptive, curative remedies. Routinely, inadequate thought and care are given to the narrative that the living, breathing individual is constructing. Shirley’s words cap-ture what we hope this book conveys, and so we thank her for graciously allowing us to present her musings as the foreword to this third edition.

Audrey and Ryan

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ForeWordby shirley morgenstein

“I am convinced that the very inability to articulate the contradictions of disability and identity within rehabilitation is perhaps the force that drives professionals and patients to the safe haven of science and objectivity.”

Carole Pound

T his makes sense when looking at the traditional ways we approach therapy: The client is damaged goods; the therapist is the fixer; and the goal is to strive for normal or near-normal func-tion. Pound talks a lot about the “seductive” notion of cure. We get sucked into it, and so does the person with aphasia. It is a promise we cannot fulfill, but we make it anyway. We spend virtually no time in our training learning how to help people INTEGRATE the new identity of person-with-disability, let alone our own reaction to what that means for us as therapists. It means having to listen to the suffering narratives, the stories of who they were “before,” and accepting that we cannot make the aphasia go away, or we cannot teach compensatory strategies, or a million other things we hold dear in our profession. This, the decade of the brain, is exciting in the projection of a future in which we can zap a cortex and plug it in to exercises and make it better. Is it also perhaps a retreat into the past philosophy of our role as fixers? Are we afraid to go forward into the inner self, accepting disability and helping others with the new narrative?

In my work at rehabilitation hospitals, I have seen the anger and frustration that builds in speech-language pathologists who deny this reality. They are stymied at what seems like a lack of motivation or dedication on the part of the client and at their own feelings that rise up when they cannot get the desired outcome. Threatened by the enormous challenge of an empathic effort to understand what the client is feeling, they retreat into science, talking about statistics in EBP studies to anxious wives, or the

xii Counseling in CommuniCation DisorDers

relationship between site of lesion and symptomatology. Rehab, by definition, is the place where people go to get better, not the place to integrate a new reality.

It is safe there, in the world of statistics and probabilities and research studies, which cite percentages of improvement with this technique or another. How, then, to learn to love the place where things are totally unknown, and change the therapist narrative?

Shirley MorgensteinRelationship and Reflection in Aphasia Therapy, 2016

xiii

PreFACe

T his book comes from our hearts. It is not a scientific treatise on counseling; rather it describes a counseling attitude and explores how speech-language pathologists and audiologists can enrich their clinical practice using specific skills and techniques that incor-porate that attitude.

The book also has a strong theoretical orientation in positive psychology and wellness. This means that it basically abandons our profession’s long history of building our counseling on principles intended for the treatment of individuals with recognized psycho-pathology. Instead, we build on principles that essentially empha-size what is right with people. We believe strongly that across the lifespan, people who incur communication disorders (and their families) have a far greater likelihood of being recipients of unfor-tunate things that happen to many of us as we bumble along in the essentially big normal space in the middle of the Gaussian distribu-tion, instead of clustering around its lower edges. Essentially, this has made us wonder why our profession’s counseling foundation is based on (perfectly good but inappropriate) counseling principles that are intended for helping people with “problems.”

Although “on-the-firing-line” professionals who pick up this book might be able to sneak around its child chapters, if they work with adults, or its adult chapters, if infants and school-age children are the focus, but students (bless you) can’t circumvent any of them. In fact, all the chapters relate to each other and are intertwined. We believe that a thorough reading of the whole book and the interplay among its various parts is the way to get the most out of it.

Our hope is that as you read each of the first three chapters, you will experience the same synergistic feeling we did as we attempted to explain the foundations of positive psychology and counseling. The next four chapters illustrate and apply these prin-ciples across the lifespan and in a variety of traditional settings. Holly Damico and Jack Damico have lent their expertise in coun-seling parents of children with or at risk of communication disor-ders to our work in Chapter 4, which is new to this third edition.

xiv Counseling in CommuniCation DisorDers

Chapters 5 through 7 have been updated and expanded to include new research findings and additional applications for counseling across the lifespan. Chapter 8 is a gift from Stan Goldberg. Here, he considers the communication counseling issues associated with death and dying through the attitude of dignity and the reverence it deserves. Chapter 9 presents an additional model for helping clients and families benefit from the principles of wellness detailed in earlier chapters. A framework for conducting workshops specifi-cally teaching resilience and optimism is described with a number of practical examples and activities. We believe, and several uni-versity professors have shared, that this final chapter functions wonderfully in settings in which individuals are interested in devel-oping and honing communication counseling skills.

We have loved cooperating on the writing of this third edition. Audrey learned a tremendous amount from Ryan about toddlers and school-age children and issues faced by SLPs and audiologists in school settings. In turn, Audrey’s expertise with adults and with life coaching and counseling greatly enhanced Ryan’s understand-ing. We hardly ever got even slightly annoyed with each other in our long-distance, e-mail–besotted cooperative efforts. So we guess this is what happens when two people who have caught the posi-tive psychology bug work on a project such as this. We positively enjoyed the experience and hope that you do, too.

Namasté~—Audrey Holland, Tucson AZ—Ryan Nelson, Lafayette, LA

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Contributors

Holly Damico, PhD, CCC-SLPDoris B. Hawthorne — BORSF Endowed ProfessorUniversity of Louisiana at LafayetteLafayette, LouisianaChapter 4

Jack Damico, PhD, CCC-SLPProfessor and Doris B. Hawthorne Eminent Scholar Chair in

Communication DisordersAssistant Vice President for ResearchThe University of Louisiana at LafayetteLafayette, LouisianaChapter 4

Stan Goldberg, PhDProfessor Emeritus Communicative DisordersSan Francisco State UniversitySan Francisco, CaliforniaChapter 8

Audrey L. Holland, PhDRegents’ Professor EmeritaUniversity of ArizonaTucson, Arizona

Ryan L. Nelson, PhDDoris B. Hawthorne-BORSF Endowed ProfessorUniversity of Louisiana at LafayetteLafayette, Louisiana

Audrey: To the many people I love and honor . . .

Ryan: To those who graciously continue to model wellness, love, and resilience . . .

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Chapter 1

Counseling in CliniCal PraCtiCe: overview

introduction

Speech-language pathologists and audiologists (SLP-As) bring expertise in specific clinical areas to the evaluation and manage-ment of communication disorders. Both students and practicing cli-nicians need to develop counseling skills if they are to serve clients and their families effectively. Counseling is necessary to support decisions and behaviors that optimize quality of life. Knowledge of effective counseling techniques supplements the professional’s knowledge about communication disorders and his or her skills in managing these disorders. Finally, appropriate counseling greatly increases the opportunity for an optimal outcome for clients, whether this involves resolving a specific disorder or maximizing quality of life by means of coping and adjustments.

The role of speech-language-hearing professionals is usually complex. Children with severe hearing losses or cerebral palsy, along with their families, face lifelong struggles. Difficult problems arise at the other end of the age spectrum as well: Adults (and their

2 Counseling in CommuniCation DisorDers

families) who acquire aphasia or dementia or TBI must learn to deal with profoundly changed lives. Our treatment goals for indi-viduals with communication disorders are certainly to minimize the disorder’s effects, but counseling also can help involved persons to live productively and successfully with the communication prob-lems, or despite them, or around them.

Effective counseling principles are both learnable and fairly general: The techniques and skills are similar for helping a fam-ily with a new baby who has a cleft palate or a hearing deficit and for supporting an adult client with post-stroke aphasia, and his family, who face the realities of living with impaired commu-nication. The disorder-specific facts differ, of course, and require disorder-specific understanding of them as well. According to the American Speech-Language-Hearing Association’s (ASHA) Scope of Practice statements for speech-language pathology (2016) and for audiology (2004), counseling is an integral part of clinical respon-sibility for both families and children with speech, language, and hearing disorders, and for adults who have acquired such disor-ders. Counseling is our basic tool to help clients achieve their lifelong goals. SLP-As often feel uncomfortable about the counsel-ing role, however, and consequently we are reluctant to under- take it.

A number of reasons may underlie this reluctance. Perhaps a lack of explicit training in counseling explains it. During our pro-fessional education, we are given a wealth of information about the potential problems confronting individuals and families with communication disorders but are taught very little about how the counseling process can be used to help resolve them. Indeed, the ASHA provides no curriculum requirements for SLPs. Counseling is likely to be tagged onto the end of disorder-specific courses, rather than presented in its own right as a skill to be learned through coursework and practice. The curriculum for AuDs is more enlight-ened; a counseling course is required.

Counseling for individuals with communication problems has been strongly influenced in the past by traditional concepts derived for counseling individuals with psychological problems. Basic information concerning Freudian defense mechanisms, and the client-centered approaches pioneered by Carl Rogers (1995), have been particularly influential in our field. We suspect that

1. Counseling in CliniCal PraCtiCe: overvieW 3

another factor contributing to the reluctance of SLPs to assume a counseling role is that we recognize the implicit mismatch between the forms of counseling originally developed for individuals with disorders such as anxiety or depression and the problems faced by individuals who stutter, or for a family with financial problems stemming from the breadwinner’s Parkinson’s disease or incapaci-tation following a motor vehicle accident. People who are in need of communication counseling are likely to have been coping with their lives fairly normally before the onset of the communication disorder. This is not to say that individuals with psychological or behavioral problems are immune to communication problems, but a majority of the people for whom SLP-As provide counseling or coaching probably react to the world in ways that are not patho-logic. The abnormal models of counseling do not fit very well; they are difficult to apply in clinical practice, even after we have taken a course or two in abnormal psychology. Most communica-tion problems have unique, significant, and reverberating effects on families, who are likely to be as unprepared for them as those who actually incur the problems. Our discipline’s reliance on abnormal psychology has seldom been questioned or examined, although it may explain at least partially why many practitioners feel uneasy with their counseling roles. We will have more to say about this later in this chapter.

In this book, counseling for communication disorders has a different theoretical perspective. This approach requires essen-tially abandoning a treatment model based on what is wrong with people who have such disorders. Instead, the emphasis is on what is right with them, and how they can mobilize their strengths to deal with the adversities that have befallen them as the result of an unexpected event that threatens one of the most basic human characteristics — the ability to communicate. Thus, the counseling process starts with the assumption that the cup is half full, not half empty. Before onset or recognition of a communication disorder, the affected person and his or her family — whether an adult client who has experienced a stroke with resultant aphasia or the parent of a newborn infant who has been found to be at risk for such a disorder, for example — probably already have been coping reason-ably well with life stresses. How do we as counselors capitalize on, and build on, the positive?


themes of interest

Five themes that focus on how to help individuals with commu-nication disorders to develop optimism and resilience constitute a framework for this book. These themes are described next, in no implied hierarchy; all are equally important.

theme 1: Wellness and Positive Psychology

Much of the content of this book is based on a conviction that appropriate models and approaches for communication counseling should be grounded in what we know about normality and wellness rather than in what we know about illness and psychopathology. The recent explosion of information about and interest in positive psychology provides the best example, particularly as it is illumi-nated by the work of M. E. P. Seligman and his colleagues. Here is just a sampling of relevant books on positive psychology pub-lished since 2002, following the publication of Seligman’s Authentic Happiness, which was published then. Some of these important books include Ben-Shahar, 2010; Diener and Biswas-Diener, 2008; Fredrickson, 2009; Haidt, 2006; Peterson, 2006; Reivich and Shatté, 2002; and Seligman’s more recent book (2011), which significantly increases the worldview of the movement. More detailed explora-tion is central to Chapter 2 of this book.

The first theme of this book, then, is its reliance on the prin-ciples and tenets of positive psychology, focusing on mental health and well-being and how to achieve and maintain them. Positive psychology is oriented away from illness and toward wellness, both for understanding what it means to live positively and for providing ways to increase authentic happiness in one’s own life and to promote a healthier society in general. This book links those principles to counseling individuals and families who experience and live with communication disorders.

One of the most appealing aspects of focusing on wellness and positive psychology as a counseling model in communication disorders is that it fits squarely with the facet of counseling with which SLP-As are most comfortable: providing information. We are skilled educators and good providers of information. Train-


ing in speech-language pathology and audiology produces good teachers, whether we are teaching children to move a lateral lisp into a more acceptable /s/ production, or reestablishing semantic skills in aphasic adults, or teaching effective hearing aid use. We are also competent interviewers, who, through questioning, can ferret out the relevant and pertinent facts concerning why a fam-ily or client is sitting before us. Interviewing, however, is NOT counseling.

Counseling is a change process, as are many of the other techniques used by SLP-As. To the extent that our counseling can capitalize on our teaching skills, we can become comfortable with a counseling role. A core feature of positive psychology is its devel-opment of explicit ways to increase resilience and optimism. These two attributes are particularly critical for learning to cope with the many disasters or catastrophes that occur in the process of simply living life. Basic principles of positive psychology are covered in Chapter 2. Experimentally-validated exercises related to positive psychology will be presented there, and additional exercises that have been adapted specifically for communication counseling are scattered throughout the book.

theme 2: Living the Catastrophe, dealing with the Crisis

In this book, the words “catastrophe” and “catastrophic” gener-ally are used in the conventional sense of disaster and disastrous. They imply the kinds of wrenching problems that result from the spectrum of communication disorders ranging from developmental disorders discovered in infancy to the dementias that occur late in life. But catastrophe is also used in this book in the sense that Jon Kabat-Zinn used it in his book on stress reduction and meditation, Full Catastrophe Living (anniversary edition, 2005). Kabat-Zinn bor-rowed his title in part from Kazantzakis’ Zorba the Greek (1996). In the film adaptation of Kazantzakis’ book, Zorba responds to the question of whether he was ever married: “Of course I’ve been married. Wife, house, kids, everything . . . the full catastrophe!” Kabat-Zinn interpreted Zorba’s remark as a basic appreciation of the roller-coaster nature of being alive. This usage of the word catastrophe embodies the spirit of accepting change and knowing that, in Kabat-Zinn’s words:


. . it is not a disaster to be alive just because we feel fear and we suffer . . . [to understand] that there is joy as well as suffer-ing, hope as well as despair, calm as well as agitation, love as well as hatred, health as well as illness . . . (p. 5)

The “full catastrophe” for most people involves good and bad, easy and hard, periods of happiness and periods of pain. In fact, someone who manages to avoid the negatives may be perceived in some way as diminished (and perhaps likely to be rather boring!). Although the issues we deal with in our communication counseling gravitate toward the negative pole, it is crucial to remember that the opposite, the positive, also is there. Good counselors respect and honor not only their clients and their problems but also the “full catastrophe” of the human condition.

Crisis models may be useful for clinicians who deal with the full catastrophe of parents experiencing that their child has Down syndrome, or that aphasia has resulted from the stroke one’s hus-band has incurred. Before most people can accept the bad, they have to acknowledge it and come to peace with it. Crisis mod-els, exemplified by Elisabeth Kübler-Ross’ approach to dealing with grief, death, and dying (1969), have been useful with many chronic health issues as well. Although her model has significant shortcomings, as adapted by Webster and Newhoff (1981) for our professions, it can be useful for elucidating the process whereby individuals can learn to deal with catastrophic events.

Four stages are postulated to occur as individuals progress toward healthy resolution. These stages are called various names by various authors. In this book, Webster and Newhoff’s terms are used. These are, in order, shock, realization, retreat, and acknowl-edgment. Certainly, not all individuals go through all stages in an orderly fashion, and not all individuals actually reach satisfactory acknowledgment. In fact, Goldberg (2006) commented that in his extensive experience as a hospice counselor, he has never observed an individual who followed precisely these stages of grief. Never-theless, these stages should be kept in mind by SLP-As for their counseling work with parents, spouses, and persons who have experienced sudden catastrophic illnesses.

Immediately after a catastrophe, neither the family nor the person who has experienced it is in a particularly good position to take advantage of new information. Nevertheless, almost with-out exception, experienced clinicians routinely provide it. Fre-


quently, however, SLPs whose work focuses on chronic aphasia hear comments from clients and their families that “things were not explained” and that they had no idea what to expect. In such instances, the shock of the stroke may compromise the ability of the affected person and family members to absorb new information in the earliest stages of recovery. This limitation does not mean that clinicians should stop providing information in the initial aftermath of a potentially disabling event. But we should not be surprised when affected individuals and families fail to comprehend all of the early information they receive, and we should be prepared to repeat it, perhaps frequently. Of greater importance, this initial fail-ure to comprehend or retain relevant information means that the first of Webster’s (1977) counseling functions — listening — should be primary. Webster points out that listening to what people want to share and simply holding hands and being present are what matters at this time. It also is valuable to provide information that is more permanent than the spoken word. Pamphlets, refrigerator magnets, videotapes, and contact information sheets will be useful later, when the realization stage is reached. When the client and family members realize what this problem may actually entail, written information and relevant telephone numbers can be used productively.

Retreat is likely to be the least universal of these four crisis stages, at least for the types of problems encountered by SLP-As; however, retreat can manifest as denial that a problem actually exists or that the disorder will have a major impact in the long run. For example, Dora, the spouse of a man who has recently suf-fered a major stroke, comments, “Ralph may have global aphasia, but you don’t know his will. He’ll be back to work at his old job in 6 months, mark my words.” As counselors, we must be aware of the delicate nature of such denial, as well as of the need to deal with denial when it occurs.

It is not uncommon for clinics to have spouses rate communi-cation of their communication-impaired partner using the Commu-nication Effectiveness Index (CETI) (Lomas, Pickard, Bester, Elbard, Findlayson, & Zoghabib, 1989). A frequent outcome is that early in the rehab process, spouses rate their partners as substantially higher than on CETIs taken later in the recovery process. After families have lived with a disorder for a longer period of time, problems often become more apparent. When Dora realizes Ralph is not back at work yet, and that their future may be very different from the one she has envisioned, counseling offers the mechanism for her reassessment.


Acknowledgment of the problem is not a synonym for giving up. Acknowledgment is recognizing the reality of the individual’s condition, making room for the changes, and moving on with life. Ram Dass (2000, p. 185), who completed his book Still Here after experiencing a stroke that resulted in aphasia and hemiplegia, elo-quently described the good that resulted from acknowledging his deficit. He comments:

The stroke was like a samurai sword, cutting apart the two halves of my life. It was a demarcation between the two stages. In a way, it’s been like having two incarnations in one; this is me that was “him” . . . Seeing it that way saves me from the suffering of making comparisons, of thinking about the things I used to do but can’t do anymore because of the paralysis in my hand. In the “past incarnation” I had an MG with a stick shift, I had golf clubs, I had a cello. Now I don’t have any use for those things! New incarnation!

Since we wrote the previous edition of this book, Ryan and Audrey have become aware of the work of Richard Tedeschi and Lawrence Calhoun (2006, 2013) on posttraumatic growth. These researchers and their colleagues have been active in the looking both at posttraumatic stress disorder (PTSD) and its sequelae since the mid-1990s. The problems of PTSD have been well recognized since “shell shock” following World War I. However, the term PTSD became a household word following the Iraq War and its return-ing, wounded warriors. Tedeschi and Calhoun and their students have chosen to look at the bright side, not only at the substantial numbers of survivors of PTSD who surmount it, but for the large majority of resilient, optimistic survivors of catastrophic events who do not experience it.

More will be said about PTG in the next chapter, but its impor-tance for parents of children with unforeseen or unexpected prob-lems, and for adults with later developing problems are substantial and significant.

theme 3: Change

Implicit in the above is that, as people live into their “full catastro-phes” and move through their crises, differing counseling needs

counseling in communication disorders

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